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112 Cards in this Set
- Front
- Back
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What is the most common internal tumor in US males? |
Prostate Cancer
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What is the second most common cause of cancer death in US men? |
Prostate Cancer |
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What percentage of pCA are thought to be clinically significant? |
25% |
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What is the most common type of pCA? |
Adenocarcinoma |
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How does Advanced prostate cancer present? |
Bone pain, voiding symptoms, hematuria, urine retention, hydronephrosis |
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What increases one's risk of pCA? |
Family history of prostate cancer african american race age >65 |
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What are the common areas for pCA mets? |
pelvic lymph nodes bone lung liver |
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What percentage of TURP patients have incidental pCA? |
10 |
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What percentage of radical cystectomy patients have incidental pCA? |
28-61 |
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What percentage of dead patients over age 80 have pCA? |
48-87% |
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Aside from 95% of pCA's being adeno, what are the other type common types |
TCC is the most common and then small cell, sarcoma, etc |
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From which cells does prostate cancer originate |
prostate epitheliel cells |
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What is cell type is missing in prostate adenocarcinoma |
Basal cells |
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What stains can be used to detect prostate cancer? |
prostatic acid phosphatase HMWK (stains for basal cells, so if its missing then its adeno) |
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What is the most common location of prostate cancer |
peripheral zone |
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Does prostate cancer tend to occur locally in the prostate or multifocally |
multifocal |
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What percentage of prostate CA is within 5mm of the urethra? |
65% |
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What percentage of prostate cancer appears in the: transitional zone? central zone? anterior fibromuscular zone? |
periph - 70% transitional - 20% central 5-10% anterior fibromus - rare |
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Where is capsular penetration most common for pCA? |
Near the neurovascular bundle |
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Capsular penetration is how much more common in peripheral zone CA than transitional zone? |
2x |
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What characteristics increase the risk of capsular penetration? |
1. Higher clinical stage 2. Higher gleason score 3. higher preoperative PSA |
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What percentage of men with atypia develop prostate cancer? |
40-60% |
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Does atypia alter PSA? |
No |
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How do you manage atypia? |
Rebiopsy in 3 months with increased sampling of the atypical region |
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What is prostatic intraepithelial neoplasia |
it is a pre-malignant dysplasia of the epithelial cells. There is a basal cell layer. |
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How do you manage low grade prostatic intraepitheliel neoplasia? |
do an annual DRE and PSA - rebiopsy if either is concerning |
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How do you manage high grade prostatic intraepitheliel neoplasia? |
Monitor PSA and DRE and rebiopsy the prostate in 1-3 years. |
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Finasteride can decrease the risk of prostate cancer by 25%. What is the controversy surrounding finasteride and prostate cancer. |
The data initially suggested that low grade cancers were decreased and high grade cancers were increased with finasteride. Upon further inspection of the data this did not seem to actually be the case. |
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Dutasteride can decrease the risk of prostate cancer by 27%. What is the controversy surrounding dutasteride? |
It decreased gleason 5-6, but had no effect on 7-10. It did decrease the risk of high grade PIN and atypia. |
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What is the effect of Vitamin E, Vitamin C, and Selenium on the risk of prostate cancer? |
There is no effect. |
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What are the effects of screening for prostate CA? |
cons: increased cost and mental anguish while detecting many low grade cancers
pros: prolongs survival is inconclusive |
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What life expectancy should be the cut-off for prostate cancer screening? |
If they have <10 year life expectancy, do not screen. |
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At what age should prostate cancer screening be started? |
40, but not neccessarily annually until age 50, unless they are at high risk (family members, african american, etc) |
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The patient has a PSA of 2.5. How often should his psa be checked? |
annually |
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For men in their 40's, what is the median psa? |
0.6 ng/dl |
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What percentage of prostate cancers detected by screening are localized? |
>90% |
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What can elevate the PSA? |
genitourinary infection ejaculation prostate trauma prostate biopsy urethral instrumentation prostate massage cycling prostate cancer BPH |
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What constitutes an abnormal DRE? |
asymmetry, induration, nodules, enlargement, palpable variations
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A man has a slightly elevated PSA. What is the next step? |
Wait at least three weeks and then recheck the PSA making sure that none of the things that can elevate the psa are present. |
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What is an absolute indication for a prostate biopsy? |
suspicious DRE |
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What are the two patient characterisitics that should be used in deciding what a high PSA is? |
Age and ethnicity |
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A patient has a psa 4-10. What can be checked to give you more information about this? |
Free psa |
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A patient has a psa less than 4. What psa velocity would be concerning enough to do a biopsy? |
>.35ng/ml/year |
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A patient has a psa greater than 4. What psa velocity would be concerning enough to do a biopsy? |
>.75ng/ml/year |
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A man is taking a 5 alpha reductase inhibitor. What is a concerning elevation of the psa? Also, when should you biopsy? |
Any elevation is concerning enough to biopsy Also biopsy if they have not dropped by greater than 50% 12 months after starting the 5ARI |
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a PSA density (psad) is concerning at what value? |
greater than .15 |
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a very low % free psa is (<10%) and significant for what? |
Very concerning for prostate cancer
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What ethnicity has the highest risk of pCA? |
African american Asian american Caucasian |
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A 70 year old: caucasian has a psa of 6.5 African american has a psa of 5.5 asian american has a psa of 5.0 Which has the highest risk of pCA? |
These are all respectively normal |
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What are the three main indications for prostate biopsy? |
abnormal DRE abnormal psa abnormal change in psa |
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Should the patient have a bowel prep before transrectal prostate biopsy? |
There is no evidence that this decreases the risk of infection |
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What kind of antibiotic prophylaxis should the patient get for prostate biopsy? |
They should have a flouroquinolone immediately before the biopsy. If they are high risk for infection then continue after the procedure |
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What will prostate cancer look like under ultrasound and what if it is a big mass? |
It will normally be isoechoic because it is usually very very small. If it is larger then it will be hypoechoic. |
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Where does the prostate innervation come from and where is a prostate block placed? |
nerves arise from the symp and parasymp branches of the inferior hypogastric plexus. They course along the post-lat prostate from the base to the apex. |
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How is prostate block performed and using what anesthetic? |
using 1% plain lido inject 2-5ml for each side into the tissue between the prostate base and the seminal vesicle. You can also inject into the base/mid/ and apex of the prostate. |
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What is the name of the anatomical division between the part of the rectum that will feel severe pain and will not feel severe pain. |
dentate line (pectinate line, anorectal junction) |
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What nerves innervates the tissue above and below the pecinate line |
above the pectinate line is the branches of the hypogastric plexus below the pectinate line is the inferior rectal nerve |
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Which part of the prostate is the most important to gets specimens from during biopsy? |
The peripheral zone. |
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How many cores does the AUA recommend? |
8-12. but many people take 14 |
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What is the pattern of the prostate biopsy cores? |
4 para-sagittal cores (base, mid, apex, and anterior apical) 3 lateral cores (base, mid, apex) |
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If pCA is missed on biopsy, which part of the prostate should be biopsied? |
the anterior-apical peripheral zone the midline peripheral zone anterior transitional zone
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What is a saturation biopsy and what is the role? |
It is when at least 20 cores are taken throughout the prostate and it should be done if there have been two negative 14 core biopsies with no results and still high suspicion |
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What is transurethral biopsy? |
It is a prostate biopsy through the urethra and has litte role because most tissue can be assessed transrectally |
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When should seminal vesicle biopsy be considered? |
When men are considering salvage cryotherapy, because 42% of recurrence after radiation appears in the seminal vesicles. |
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If severe rectal bleeding is occuring after transrectal biopsy of the prostates, what management options are available? |
digital pressure lubricated rectal packing foley balloon foley balloon with rectal packing anoscopy with suture ligation of the vessel |
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What is the workup, once prostate CA is detected from biopsy? |
1. CXR 2. Bone scan if psa >20, clinical stage t3-t4, gleason 8,9,10, high alk phos, high CA++ 3. pelvic CT or MRI if nomogram indicates >20% risk of lymph node mets or if any of the above bone scan values are high. 4. Prostascint and/or endorectal MRI - if bone and pelvic CT are negative. |
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If a patient has suspected bone mets, what is the workup schedule? |
1. bone scan 2. plain xrays 3. ct or mri 4. biopsy |
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what are the stages of prostate cancer? |
tx - cannot be assessed t0 - no prostate cancer detected t1 - clinically inapparent tumor - neither palpable or detectable by imaging t2 - tumor confined to the prostate t3 - tumor extends through the prostate capsule t4 - tumor is fixed or invades adjacent structures other than seminal vesicles
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How are nodes and mets staged? |
nx - not assessed n0 - no cancer in nodes n1 - positive nodes
m0 - no distant mets m1 - positive for mets |
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Where are the regional lymph nodes located for the prostate? |
below the bifurcation of the common iliac arteries |
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Gleason scoring is based on what? |
Architecture of the glands. Cellular characterisitcs are not used. |
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The gleason score is calculated by adding what two numbers together? |
The most abundant and the second most abundant grades visible. |
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What is the lowest gleason grade possible? |
2 |
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What is the highest gleason grade possible? |
10 |
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the three characteristics used to describe the glands for gleason scoring are: |
is the tumor confined to well-circumscribed nodules? is there strome present between each gland? is there variability in gland size and morphology |
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The most straightforward aspect of gleason grading is checking the variability in gland size and morphology. What are the 5 stages? |
1. no variablility (large, uniform glands) 2. minimal 3. moderate 4. fused, back to back glands or cribiform 5. no glands, just sheets or nests |
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What are the four characteristics of PCA of pretesting that predict high risk of death? |
1. psa velocity great than 2/year 2. high psa at diagnosis 3. biopsy gleason score 8-10 4. palpable nodule |
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The three risk levels of prostate cancers are low, medium and high. What are the three criteria that go into these levels? |
psa, gleason score, clinical stage |
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What psa, gleason score, and clinical stage makes a person have "low risk prostate cancer"? |
psa < 10 gleason <6 clinical stage t1 or t2a |
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What psa, gleason score, and clinical stage makes a person have "medium risk prostate cancer"? |
psa 10-20 gleason score 7 clinical stage t2b-t2c |
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What psa, gleason score and clinical stage makes a person have "high risk prostate cancer"? |
Psa great than 20 gleason score 8-10 clinical stage 3 |
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how frequently do you monitor men with prostate cancer? |
check a psa and do a DRE every 3-6 months. If they are fine for a long time then this duration can be increased. |
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What are the treatment options for localized prostate cancer? |
1. radical prostatectomy 2. external beam radiation 3. brachytherapy (with or without xrt) 4. particle beam therapy 5. crytotherapy 6. surveillance |
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What is the treatment of choice for men under age 50? |
In men under age 50 radical prostatectomy significantly increased survival at 15 years over surveillance or external beam radiation therapy. |
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for men over age 50 with low grade cancer, what is the treatment of choice? |
All of the following have similar outcomes: rp, xrt, brachy, cryo |
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For men over age 50 with high risk prostate cancer, what is the treatment of choice? |
Brachytherapy alone and cryotherapy alone have lower cure rates than RP alone. combination may be beneficial |
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What is the most common internal tumor in US males? |
Prostate cancer |
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What is the sensitivity of the DRE for prostate cancer? |
30% have cancer after suspicious DRE |
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pca3 does what? |
gives you a risk of prostate cancer |
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radiation therapy achieves longer survival than no curative therapy in men as long as they are under what age? |
75 |
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for men older than 65, not received curative therapy, with a gleason score 8-10. What is the 10 year survival rate? |
26% |
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What makes a person a good candidate for surveillance? |
life expectancy less than 10 years and low grade prostate cancer |
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After a patient has been on active surveillance for 1 years, a rebiospy is performed on their prostate. What percentage will be upgraded? |
30% |
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What is cryotherapy? |
freezing tissue aka coagulative necrosis |
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How does freezing with cryotherapy actually kill cells? |
1. cell rupture 2. apoptosis 3. ichemia |
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from which direction, to which direction, is the prostate frozen and why? |
It is frozen from anterior to posterior. This is because the frozen tissue does not allow ultrasound waves to pass through it, so the part of the prostate closest to the rectum must be frozen last. |
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To what temperature is freezing attempted? |
-40C for two freeze/thaw cycles |
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What is the difference between the necrosis zone and the injury zone during cryotherapy? |
the necrosis zone is in the center and is the part that is -40C. The injury zone is outside of that zone and is somewhere between 0c and -40C and there will be some damage here |
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What are the negative aspects of cryotherapy? |
ED is very common men with previous turp have a higher risk for urethral necrosis and sloughing men with large prostates have less success pelvic lymph nodes are not effected
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Who is a good candidate for cryo? |
stage t1-2 n0m0 who have not had a turp |
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What is done to protect the urethra during cryotherapy and why is this an issue for pCA? |
There is warm water running through the catheter. This saves the urethral tissue, but 35-45% of prostate cancer is within 1mm of the urethra |
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What can you expect from psa after cryo? |
It will go down, but not to castrate levels because of the prostate tissue around the urethra. |
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What percentage of men have a negative prostate biopsy after Cryo? |
90% |
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What are the side effects of cryo? |
bladder outlet obstruction genital swelling penile parasthesia ED (50-92%) urethral sloughing rectal pain urinary incontinence fistula
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What is radical prostatectomy? |
Removal of the entire prostate by laparascopic or open technique (retropubic, perineal, or trans scrotal |
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What is nerve sparing? |
It is removing the neurovascular bundle from the posterior capsule of the prostate on the posteriolateral sides of the prostate. |
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When can nerve sparing be done safely? |
t1-t2, psa <10, gleason <7, small volume of cancer, good preoperative potency |
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When is pelvic lymph node dissection not required? |
low grade, t1-2a, psa <10, gleason score <6 with no score 4 or 5 |
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Removal of lymphatic tissue anterior and lateral to the external iliac vessels increase the risk of what? |
lymphedema |
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What are the complications of lymph node dissection? |
Injury to the vessels lymphocele lymphedema obturator nerve injury |
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How can you tell the difference between a urinoma and a lymphocele? |
Check a spot creatinine on the fluid. It will be very high for a urinoma, but it will be the same as the serum creatinine for a lymphocele. |
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What are the side effects of radical prostatectomy? |
ED stress urinary incontinence <5% permanent infertility and aspermia always occur bladder neck contracture
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